GB

Last week saw the “worst week in A&E” since monitoring began in 2010.

Much has been made in the media about the number of people breaching the four-hour target. There is also a shocking lack of understanding of what the four-hour target actually means.

The target is not for patients to be seen by a doctor in four hours. The target involves patients being booked in at the front desk, assessed by nurses, triaged by frontline Consultants, having blood tests and other investigations performed, being fully clerked and examined by another doctor, having a diagnosis made, being referred to a specialty team, and then leaving the department to go to a bed on the ward, or being discharged home.

I don’t have to point out that the potential for delay here is almost unquantifiable.

During my shifts in ED I would frequently pick up patients who had twenty minutes to go. I would sometimes pick up patients who had already breached. Usually, these patients had been streamed to the urgent care centre, and then referred on to ED. Because it is technically the same department, they come through on the same clock… So, from the point of view of the four-hour target, we have failed before we have even started.

The target has good and bad points. It is an arbitrary, statistically useful but morally obsolete tool, to aid us in defining our parameters and assessing our performance. It is as useful or useless as any predetermined timeframe, and the number itself is not the issue. The problem occurs due to the fixation on the target above other priorities. Used properly, the target helps us identify areas of weakness, and departments that are struggling to see their patients safely. In an ideal world, departments with more breaches should get more funding, for higher staffing levels, for increased number of observation beds, for larger majors areas. In reality, breaching leads to stressful conditions, forced decision-making, and compromised patient safety.

There are a few funny internet memes floating around about the ED. One of them states “save three people’s lives and no one bats an eyelid; breach one patient and all hell breaks loose.” I have been blessed with working in an ED where there are excellent working relationships amongst the staff, and patient safety is consistently a priority. Even so, I have often felt pressured to make a quicker decision about a patient, to take down the half bag of saline still running, to amend the timing of my medical entries in order to have one less breach.

Quite often, the balance of admission or discharge in ED hinges on a period of observation. It is impossible to accurately assess a patient’s condition in 20 minutes. The luxury of allowing them to sit in the department, with regular observations, and pain relief/a bag of fluids is often all that is needed to avoid an acute admission. Where I am working currently, they have recently reduced the number of ED observation beds from 20 to 4. This is in order to build a much-needed Acute Medical Unit, which in turn helps free up the ED by providing an exit strategy for medically accepted patients. However, this has significantly reduced the number of people we can observe prior to admission. These people are now sat on the AMU, occupying the beds that they would have occupied on an observation ward, only now they are being clerked by an additional team; there is a whole host of admission paperwork; and they will inevitably stay overnight, costing the NHS an additional £600 per patient.

The media is making much of the fact that higher ED attendances are leading to overcrowding and pressures on departments. This is only partially true. Yes, there has been a steady, expected increase in attendance leading up to winter. However, the total number of ED attendances in the “worst week”, were actually lower, nationally, than a comparative week in July of this year. So why the inability to cope?

Frequently, the reason for the backlog is the occupation of ED beds and trolleys by patients who have already been referred to specialties, but are either too unstable to transfer, or there are no beds on the ward. Obviously, if someone needs monitoring, and the only monitored bed is in Resus, then we are not going to chuck them out just because they are at 4:01. This has its own issues – what do you do with these patients when you have another blue light come in?

There have been so many headlines over the past few weeks:

A&E forced to turn away patients; Patients waiting 24 hours to be seen in A&E(!); A&E closures: the meltdown…

It doesn’t take much assessment to realise that when you close down an ED, the patients that would usually attend there will need to be seen somewhere else. And yet, it seems to have come as a massive surprise to everybody that in the wake of the closure of Hammersmith ED, the surrounding hospitals have seen increased waiting times, and Northwick Park Hospital has almost consistently been on divert, causing ambulance crews to telephone ahead and take patients to other EDs in the area. 

I am a huge proponent of closing dysfunctional departments. Having worked in a failing DGH last year, I strongly feel that no ED is better than a failing ED. However, there seems to have been no foresight with the closures, and the government very much seems to be expecting existing departments to pick up the slack with no extra room, resources, or staff. Yes, there are planned improvements to the services under strain, but it all feel a little perfunctory, and will likely be too little too late. Northwick Park’s escalation measures involve turning corridors into patient beds; this is not a sustainable situation.

Lets split the answer into parts.

1. Public health

It might not be well understood by laypeople, but health is more complex than just ‘got a disease’ -> ‘got better’ / ‘died’. The concept of health is multifactorial. Most experts will refer to the ‘bio psycho social’ model of health. That is, your health, your quality of life, your ability to work and your average life expectancy, are all influenced by the different factors that make up your life. The bio (your genetics, sex, race, and age), the psychological (attitudes, behaviours, personality, copings skills, past trauma), and the social (family relationships, social support, environment, cultural norms, education). What evidence has shown us is that these different factors are almost equal in the effect they can have on a person’s health. In areas with poverty, they intersect to give a cumulative effect of mortality and illness that seems radically out of proportion to any diseases that exist in the area. (This is called The Glasgow Effect).

Take heart disease, one of the biggest killers in the UK. Genetic predisposition to heart disease exists, but it’s a minor factor in the scheme of things. Other important factors are exercise, nutrition, stress, and smoking status. The single biggest determinor for all of these factors isn’t will power, or a ‘can do attitude’ or exposure to lifestyle gurus - it’s poverty. If you’re poor, you’re more likely grow up in a smoking household, with chronic baseline exposure to stress, so you often pick up smoking young. Eating well balanced nutritious meals requires (a) money (b) time to cook and (c) an education in nutrition, three things which single mothers working three jobs lack through no fault of their own. This means their children grow up without education in nutrition, and likely form lifelong eating habits that will be statistically incredibly difficult to shake. Exercise requires safe, well-lit areas where kids can run around, and preferably also areas where they can play sports or work towards fitness goals without having to put down a sum of money. This is near impossible to find in many big inner city areas. So now you have a generation of children growing up smoking, eating poor quality food, without the means to exercise, constantly marinading in stress and the low-grade constant trauma of being poor, and having everyone you love be poor, with all that that entails - dying young of preventable diseases, getting involved in the legal system, taking drugs because when you’re chronically miserable and have nothing to lose, drugs actually feel like a pretty good option.

And this is JUST HEART DISEASE. Want to talk about chronic pain? Which disproportionately affects those without strong social support networks and resilience borne of a life that is generally otherwise manageable? Want to talk about depression and anxiety? And how it’s near-impossible to function as a human being when you’ve just had to lend your mum your rent money because debt collectors are at her door, and your big brother is in jail for a drug charge, and your dad is in hospital with lung cancer? These are the lives that the impoverished in Britain live, every day. And then they open the newspaper and see that the Tories have introduced a bedroom tax, which taxes them for that 'empty’ bedroom that’s actually their brother’s (but he’s in jail waiting for a plea deal, and the waiting times are incredibly long, and there’s no available barristers), or their dad’s disability benefits are being cut, because he’s a ‘scrounger’ - their dad, who, by the way, might have had his lung cancer picked up sooner if he’d had better access to his GP, and who might not have smoked a pack of cigarettes a day for forty years if he hadn’t had such a terrible fucking life.

The only way to improve your situation, you’d think, would be to get an education, a degree, and then you can get a job that actually puts you above the breadline - but the Tories have just cut maintenance grants for the poorest students, and raised the tuition fees at universities, not to mention slashing trade apprenticeship positions, so like fuck is that going to happen. Hopefully by the time you’re having kids the world will be a better place, but hey, we just voted for the tories again, so maybe not!

2. Social care

If you work in a hospital, the phrase you hear approximately fifteen times a day is ‘there’s no beds’. No matter what hospital you work at, there will be periods of the year when things just grind to a hault. For some hospitals that period is ‘every day that ends in a Y’.

The general flow of patients in a UK hospital is:

A&E ( should be no more than 4 hours from start to finish, but that’s pretty aspirational. The first assessment is made, life-stabilising treatments are done, primary investigations are ordered)

Admissions Unit (patients can stay for around a day or two, decisions are made regarding the long term plan. Can they go home after a short course of antibiotics, or do they need to see a specialist doctor and go to their ward?)

Ward bed (a few days to ??? indefinite. Long term medical plans are made and acted upon. Any person who is too unwell to be at home by themselves basically lives here until they’re better)

Discharge (you go home, or, if you’re too old and frail to look after yourself, you go to a care home or equivelent).

When things grind to a hault, there’s no movement, fewer patients are getting discharged than are being admitted, there’s no beds in the hospital wards left, so people start piling up at the front door. This is how you get photos of children sleeping on the floor with IV drips in their arms. I personally have sat on the floor to put IV drips into little old demented people’s arms more than once. If you’ve never been in an A&E in a crunch situation like that, then you should count yourself very lucky. It’s reminiscent of a war zone.

Of course, in settings like this, mistakes are made, things get missed. A common solution to bed crisises is to ‘board’ patients - i.e. move them to a ward that isn’t their own, limiting their access to specialist nurses and doctors whose main base is their own ward. This boarding process can happen overnight, and it’s not uncommon to literally lose patients in the process, and have to spend half a morning tracking them down. It delays discharges and increases the risk of hospital acquired infections.

But why is it happening, you ask? NHS funding is a huge part of it - the hospitals aren’t big enough for the patient load, and district general hospitals are shut down without anyone accounting for where those extra patients are going to go. Another big cause is delayed discharges.

Imagine you’re an 89 year old lady. All your family lives in another country, you have nice neighbours that check in with you, but they can’t be there all the time. You get forgetful sometimes, losing keys, and worrying about lost jewelry, but you’ve not set your house on fire yet so no one’s really noticed. (You should have had home help. Someone should have been coming in three times a day to get your meals organised and help you shower, but the government hasn’t invested in the service and you’ve slipped out of the system somehow. You don’t know how to get things back in place and really, you’re perfectly alright just eating the odd slice of toast for dinner, you’re not too hungry, although your neighbour does say you look very thin). You trip over a corner of rug in your bungalow and break your hip. No one notices until your neighbours get concerned a day later, and the police break down your door, by which point you’re delirious with pain and have developed pneumonia, which has made it’s way into sepsis. You arrive in the A&E and some harried junior doctor sticks a needle in your arm and you don’t understand why, and you’re in the middle of the corridor because a nurse says ‘there’s no beds, sorry dear’, and it doesn’t matter how much you cry and scream, it feels like no one comes, and you’re all alone (they do come, but you don’t remember, you really need someone to sit with you, but no one is free because there’s 100 other people in this department and it’s only built to hold 50). Two weeks down the line, when you’ve had your hip operation, and your pain is much better, and you’re getting about with a stick - you’re still much more confused than you were, bumbling around in your little flat, and you really just want to go home - some nice nurse or doctor or physiotherapist says ‘we don’t think you’re safe to go home, we think you need to go to sheltered housing, you’ve not been eating, you mix things up, we’re worried about how you’d cope’, and you don’t really want to but your son agrees, when he phones from canada, and the doctors sem to know what they’re talking about.

You wait three weeks for a bed, because sheltered accomodation is a premium, and there’s literally not a single care home bed available in the surrounding 50 miles. To make matters worse, five of the people in the ward with you are also waiting for a care home placement. In that time, the A&E has backed up even more, because there’s no movement in the hospital. This is because the government has no plan for the aging population of the UK, or the fragmented family life that has come with the 21st century. The system already in place is fractured, under immense strain, and the problem is only getting worse. The Tories think that the best way to deal with this is to make older people pay more money for the social care they receive, which in practice means having to sell the home they raised their children in, that they lived their entire married lives in. Even when they’re 89 and the prospect of emptying and selling a family home is more than they can possibly cope with alone. 

3. NHS funding

Now imagine you’re the harried junior doctor. You work ten twelve hour shifts in a row regularly. You stay late almost every night (sometimes by hours) because you can’t do your routine work in the time you have, let alone deal with emergent problems (like a patient getting very sick) because your rota, which is supposed to have 10 people on it, only has 6 people on it, and they haven’t filled the gaps. You get called in on your days off when other people call in sick, because there’s no float, or cover. When you call in sick, you hear a pained, desperate silence on the other end of the line. You cry, regularly, in your car, in the A&E cupboard, in your room at night before grabbing six hours sleep and getting up to do it all over again the next day (which is a Saturday, all your other friends are going to a concert tonight). You cry because you’re exhausted, or because you made a mistake, or because the little old 89 year old who has absolutely no idea where she is reminds you of your granny. You’re 23 years old, you make £14 an hour, and you just held a woman’s hand while she died screaming.

You open the newspaper and see that the Torys want to make it a 24 hour/7 day NHS! That doctors nowadays aren’t working hard enough, that they have to put in more weekend shifts, because the NHS shouldn’t close at the weekends! (It doesn’t). They rearrange the junior doctor contracts so that you take a pay cut, and have to work longer and less sociable hours (guess who’s not going to be a bridesmaid at her best friend’s wedding, guess who hasn’t seen their family for christmas dinner in five years). They make out that you’re greedy child for disagreeing with this policy.

You nearly fall asleep in your car on the way home from your fifth night shift in a row - you have an hour and a half commute in rush hour traffic between you and your bed. Your hospital has five beds available for night shift doctors during the day, even though at least 25 doctors work at night.  You look down the barrel of a gun that is 10 more years of this treatment. You think about how you’d imagined your life being, and how it is. You think about how you’d like to take up a new hobby, or read a book, or see your mum. You think about the opportunities available to you abroad - half the work for double the pay. You think about how it feels to watch a 35 year old die of a disease that would have been spotted earlier had she been rich, educated, or able to advocate for herself in her busy, chronically underfunded GP surgery.

You think about how at least, at the end of the day, you have some amount of social power. Your salary will go up. You will become a consultant one day (ten years from now), and things will get better. You look at your nursing friends, who’ve had a pay freeze for the last seven years, in spite of the fact that the averge cost of living has sky rocketed. You look at the demands of their jobs, that have only gotten heavier and heavier over the years. You wonder what the fuck the incentive is there, and how, exactly, the Tory government is going to ‘keep’ the 18500 nurses that are thought to be leaving the NHS in the next few years. You think ‘I’d never let my child become a nurse, or a doctor. Fuck that shit.’

4. Your snide little bit about private health care

I’ve been working for the past 4 months in a country with privatised health care. (I’m coming back to the UK, I would never leave the NHS for good, but I needed a break so that I didn’t lose my entire shit, and I wanted to travel). Private health care does not cost ‘as much as a mobile phone contract’. Private health care warps the health systems around it like a corrosive acid. The system becomes about how best to ‘please the clients’ rather than deliver appropriate, evidence-based health care. There’s lots of discussion about how the fee to see a GP ‘discourages people who have nothing wrong with them’ and very little discussion about how, actually, rich people who have a minor cough are still very happy to see a GP, because what’s $30 to them? On the other hand, poor people with weird back pain, weight loss, night sweats, and a general feeling of fatigue put it off because ‘it’s nothing, it’s not worth the money’. (Their cancerous spinal metastases are often found too late to do anything about). Drugs cost money, so people who don’t need medication take it, because the only barrier is money and not how appropriate it is. This isn’t harmless, antibiotics have some of the highest rates of allergic reactions, which can be fatal in a small percentage of the population - if people with viral throat infections take antibiotics whenever they fancy it, there’s a rise in side effects and in antibiotic resistance, without any kind of net benefit whatsoever. Meanwhile, the prices of drugs are artificially inflated by supply and demand economics and big pharma. People who do need medication don’t take it because they can’t afford it, and they die.

Private health care kills poor people, it is systemic class warfare and genocide and it is evil. The Tories’ move to privatise the NHS will shut out health care for the poorest in the country, and - maybe even more importantly - shift the culture from one of evidence-based medicine in patient’s best interests, to a ‘give them what they want, as long as they can pay’ approach, which only degrades the quality of healthcare provided overall.

Too long; didn’t fucking read: